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;.4 <br /> Applications Will Be Processed When Submitted <br /> LICATIONp e e e <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i <br /> Application is her y made to carry on business in the jurisdictional area of the S n Jo quin��al Health Di rict� f <br /> F <br /> .US _ _Address <br />' m Business Name (DBA)— <br /> z Address <br /> Owner <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. L{ _ <br /> -J Contractor Licence No. S S'T• Date <br /> �.� G Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category (i-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> I Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i No. of Chemical Toilets Stored r <br /> 3, ❑ PERCOLATION TEST ' " <br /> R.S. or R.C.E.-No. <br /> R.S. or R.C.E. Name Test Date/Time " <br /> Test Location <br /> 4, B S—ANITATION PERMIT <br /> I ?� Z . /"1 R-, <br /> Job Address/Location Address <br /> 4 Ow ` �" S ❑ PACKAGE PLANT <br /> I SEPTIC TANK ❑ CESSPOOL D 2EPAGE PIT R"CJJ, <br /> T ❑ TEMPORARY ❑ NEW 0 REPAIR OTHER <br /> d SPyn Gl�- 1�7t'1,. <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 f ' <br /> Type Construction Disposal Site <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 'Where Certified <br /> Operator Name <br /> F Plant Location x - <br /> _ Na. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq- Ft. 7 T s <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo, <br /> I fr . <br /> I hereby certify that I have prepared.this app <br /> lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d rules an regulat' of th Sin Joaquin LocaPFiealth District. <br /> APPLICANT'S-SIGNATURE <br /> ` FOR DEPARTMENT USE;ONLY i <br /> PER UNIT p�PER SITE ❑1 EACH_ ❑ January 1 &Received.By January 31 ❑ July 1 &Received By Jul y$7 <br /> Fee Is Due: ❑ ANNUALLY ❑ 'f* REMIT <br /> • BILLING'* -REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ze� <br /> I LESS f�W <br /> PRORATIONPLUS <br /> PENALTY <br /> � OTHER <br /> ( a, S <br /> OTHER <br /> Receipt No` Permit No. I suance ate Mailed elivere <br /> Received by Date 1601 E:HAZELTON AVE.,P.O.Bax 2009 STOCK ON,CA 201 <br /> APPLICANT—RETURN ALL COPIES 10: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br />